National Suicide Prevention Trial Western New South Wales

Closing Report

February 2018

Commissioned by Western New South Wales Primary Health Network

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Prepared by: Dr Scott Fitzpatrick, Dr Donna Read, Dr Hazel Dalton, and Professor David Perkins

Commissioned by: Western New South Wales Primary Health Network

Acknowledgements: The authors kindly acknowledge the assistance provided by Phil Naden (Bila Muuji Aboriginal Health Service), Therese Gale and Sue Hackney (Western New South Wales Primary Health Network), Peter Spence (Outback Division of General Practice), and Lisa Harrison (Flourish). We would also like to extend our gratitude to all of those who gave their time to meet and talk with us.

The views expressed in this report do not necessarily reflect the final views of Western New South Wales Primary Health Network.

Report Details: Fitzpatrick, S.J., Read, D., Dalton, H., & Perkins, D. (2018). National Suicide Prevention Trial Western NSW: Closing Report. Orange NSW: Centre for Rural and Remote Mental Health.

All material in this report is provided under a Creative Commons Attribution 3.0 Australia licence (www.creativecommons.org/licenses). For the avoidance of doubt, this means this licence only applies to material as set out in this document.

The details of the relevant licence conditions are available on the Creative Commons website as is the full legal code for the CC BY 3.0 AU licence (www.creativecommons.org/licenses).

Contact: The Centre for Rural and Remote Mental Health welcomes enquiries about the information provided in this report. Please contact: Dr Scott Fitzpatrick, Centre for Rural and Remote Mental Health, PO Box 8043 Orange East NSW 2800. T: (02) 6363 8464 E: scott.fitzpatrick@newcastle.edu.au

About the CRRMH: The Centre for Rural and Remote Mental Health (CRRMH) is based in Orange NSW and is a major rural initiative of the University of Newcastle and the NSW Ministry of Health. Our staff are located across rural and remote NSW.

The Centre is committed to improving mental health and wellbeing in rural and remote communities. We focus on the following key areas:

• the promotion of good mental health and the prevention of mental illness; • developing the mental health system to better meet the needs of people living in rural and

remote regions; and • understanding and responding to rural suicide.

As the Australian Collaborating Centre for the International Foundation for Integrated Care, we promote patient-centred rather than provider-focused care that integrates mental and physical health concerns.

As part of the University of Newcastle, all of our activities are underpinned by research evidence and evaluated to ensure appropriateness and effectiveness.

Centre for Rural and Remote Mental Health T +61 2 6363 8444 E crrmh.@newcastle.edu.au

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Table of Contents

1. Executive summary .......................................................................................................... 4

2. Introduction ...................................................................................................................... 6

2.1 Background ..................................................................................................................... 6

2.2 The communities ............................................................................................................ 7

3. Aims and approach ........................................................................................................... 8

3.1 Aims ................................................................................................................................ 8

3.2 The consultations ........................................................................................................... 8

4. Key findings – The problem of suicide and community and service responses ............. 9

4.1 Perception of problem(s) ............................................................................................... 9

4.2 Clinical and service level responses ............................................................................... 9

4.2.1 Crisis support ............................................................................................................... 9

4.2.2 Discharge management and follow-up .................................................................... 10

4.2.3 Staff support and training ......................................................................................... 11

4.2.4 Staffing and funding .................................................................................................. 11

4.3 Community responses .................................................................................................. 12

5. Key findings – The scope and focus of trial activities .................................................... 13

5.1 Choice and diversity in services ................................................................................... 13

5.2 Professional and community education and awareness ............................................ 14

6. Lessons learnt ................................................................................................................. 16

7. Conclusion ....................................................................................................................... 18

8. References ...................................................................................................................... 19

9. Appendix A: List of organisations consulted ................................................................. 21

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1. Executive summary The aim of this report is to provide an overview of recent service provider and community consultations conducted as part of the National Suicide Prevention Trial in Western New South Wales (Western NSW). Work plans for individual communities have been provided under separate cover. Four Local Government Areas were selected as trial sites: Brewarrina, Bourke, Cobar, and Walgett. Consultations with key stakeholders in health and community services in each local government area were conducted between June and November 2017. Based on the information collected during these consultations, and evidence of strategies and key factors for improving suicide prevention activity and service delivery, individual work plans for each of the four trial sites were developed and presented to Western New South Wales Primary Health Network (WNSW PHN). Findings: Youth were consistently identified as a vulnerable population across the four trial sites. Informants also identified other target populations for suicide prevention activity. These included those working in mining (Cobar), those in farming occupations (Walgett), and aged migrant men (Lightning Ridge). Aboriginal and Torres Strait Islander peoples were not overtly identified as at risk; nevertheless, it was implied in discussions around intergenerational trauma, poverty, disadvantage, and the resultant problems they faced. Moreover, due to the high Aboriginal populations in the four trial sites there was an assumption that Aboriginal people were at disproportionate risk. Informants identified a number of issues related to clinical and service-level responses to the treatment and care of suicidal persons and those at risk. The main issues identified were in the areas of crisis support, discharge management and follow-up, staff support and training, and the staffing and funding of mental health and allied health services. Current targeted suicide prevention activities within the trial sites were reported as sporadic and inconsistent. Most activities centred around community events or the workplace (including schools) with the focus primarily on mental health promotion and education. There was a consensus that to most effectively address suicide risk the priority for investment should be in improved mental health, alcohol and other drug, and social service delivery. Clear disparities in service provision were observed across the four trial sites. Cobar was relatively well-served and Brewarrina was particularly disadvantaged. Diversity and real choice in services were seen as crucial. Yet many informants felt that service-users were not given a choice, and that services were designed around the needs of service providers and funding bodies rather than service users. Informants identified some scope for specific targeted suicide prevention activities. There was a consensus, however, that programs be locally appropriate and that communities and

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workplaces have a say in the design or choice and delivery of programs. Suggested areas of suicide prevention activity included: training for community and health professionals, community awareness raising, cultural identity building programs and initiatives for Aboriginal residents (particularly youth), trauma informed care training for health professionals, and education programs for families and community members to enable difficult discussions with vulnerable people. Suicide was considered a sensitive topic, and some informants expressed caution that a direct focus on suicide may discourage some from participating in local activities. Didactic approaches based on the provision of suicide prevention related information by experts to a passive target audience were considered ineffective means of communicating to groups such as Aboriginal and Torres Strait peoples and those working in farming occupations. Lessons learnt: In the course of the community consultations we came to recognise that the process of consultation in which we engaged, and that forms the basis upon which suicide prevention activities will be delivered to the communities, may not fully accord with the principles of community governance and empowerment set out in local, state, and national policies. In Western NSW, governance arrangements are in place with the Murdi Paaki Regional Assembly and its constituent Community Working Parties. Adherence to these governance structures is critical when working with Aboriginal and Torres Strait Islander communities. Conclusion: The National Suicide Prevention Trial provides an opportunity to improve suicide prevention activity targeting and service delivery to meet rural and remote community needs, and to evaluate these activities in order to build an evidence base of effective strategies. To maximise this opportunity and to ensure the successful implementation and sustainability of programs and activities, communities should be involved in an ongoing process of consultation based upon concepts of co-design, co-production, co-leadership, and mutual learning between the local community, local service providers, WNSW PHN and the Federal Government. Effective leadership and management is needed to better integrate service provision, to scale-up and provide support and mentorship to non-specialist health and community workers, and to build institutional capacity to deliver relevant training for service providers and communities. In addition, more structured support and funding should be focused on developing partnerships with non-health sector organisations to design and implement programs and interventions that address the social issues impacting social and emotional wellbeing in these communities.

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2. Introduction The aim of this report is to provide an overview of recent service provider and community consultations conducted as part of the National Suicide Prevention Trial in Western New South Wales (Western NSW). As specific work plans for each of the four trial sites have been completed, this report will draw together key findings consistent across the trial sites and discuss these in context. This section provides background to the trial and the four communities in Western NSW selected as trial sites. Section 3 outlines the aims of the community consultations and the approach taken. Section 4 presents key findings in relation to perceptions of the problem of suicide and suicidal behaviour and responses to it. Section 5 presents key findings in relation to the scope and focus of suicide prevention activities. Key learnings from the consultations are presented in Section 6. The conclusion, Section 7, discusses general understandings that have been reached in relation to this trial through the community and service provider consultation process.

2.1 Background The National Suicide Prevention Trial aims to provide evidence of how a more integrated locally planned approach to suicide prevention might be best undertaken within the Australian context. Twelve regions have been chosen for the trial. In some cases regions were selected for specific target populations (Indigenous, youth, veterans), while others were based on local need, in particular suicide deaths, attempts, and associated risk factors. Planning, funding, and implementation of trial activities is being coordinated through Primary Health Networks (PHNs) based on advice from local communities. The trial covers a three-year period from 2016-17 to 2018-19 [1]. Early engagement with communities, service providers, and service users is considered key to realising trial objectives by ensuring that activities are focused on local needs and that communities are able to provide input to planning [1]. Community engagement and stakeholder consultation will also contribute to the building of local relationships needed to support trial activities. In February 2017, Western New South Wales was selected as a trial region – one of six non-metropolitan areas chosen. In May 2017, the Centre for Rural and Remote Mental Health (CRRMH) was commissioned by WNSW PHN to undertake community and service provider consultations within the trial site of Western NSW and to assist in the development of strategies and implementation of services that support these local areas.

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2.2 The communities Four Local Government Areas (LGAs) were selected by WNSW PHN as trial sites – Bourke, Brewarrina, Cobar, and Walgett. These remote and contiguous LGAs are located in the north of Western NSW (see Figure 1). The percentage of the population who identify as Aboriginal in these LGAs is high (Bourke 31.5%, Brewarrina 61.5%, Cobar 13.7%, and Walgett 29.4%) compared to the rest of Australia (2.8%) [2]. Data collected by the CRRMH from the National Coronial Information System reported 13 suicides across the four LGAs for the period 2010-2015 (Bourke 1; Brewarrina 1; Cobar 5; Walgett 6). Data on intentional self-harm is not available. Based on 2011 census data for these populations, these figures equate to approximate suicide rates on average for each year of Bourke 6.97/100,000; Brewarrina 11.33/100,000; Cobar 21.23/100,000; and Walgett 18.59/100,000. Previous community consultations in Bourke and Brewarrina have identified long-standing concerns about service provision and the limited reach, suitability, and sustainability of programs aimed at addressing Indigenous disadvantage [3].

Figure 1 Local Government Areas/Trial Sites

Brewarrina Bourke Walgett

Cobar

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3. Aims and approach

3.1 Aims The aims and approach taken to the community and service provider consultations were as follows:

i. Begin a process of community consultation and engagement: • to establish connections with community representatives; • to outline the trial objectives and to manage community expectations

regarding the scope of the trial; • to canvas a range of opinions on suicide; local risk factors; current

infrastructure, service, and workforce gaps; and what can be done to prevent suicide at a local level.

ii. Conduct the consultations in a way that allows for further community consultation

and engagement.

iii. Adopt a broad view and to report on findings that may fall outside the parameters of the trial but that the community considers important.

3.2 The consultations The consultations were conducted with service providers and community members across the four trial sites between June and November 2017. Consultations for each site typically lasted a period of two to three days. When possible, consultations were arranged prior to travel but snowballing methods were also used to recruit additional informants across the four trial sites, and some consultations were conducted by telephone. The consultations across all four sites were conducted by CRRMH researchers, Dr Scott Fitzpatrick and Dr Donna Read. Informants held various roles within the community and represented a number of different organisations. These included health and community service organisations, emergency services, schools, shire councils, church groups, community groups and volunteer organisations (see Appendix A for a list of organisations and groups consulted). In total, 102 people were consulted (Bourke=39, Walgett=26, Cobar=15, Brewarrina=22). The four LGAs include several smaller surrounding towns. Given the budget allocated and the time pressures involved in completing the consultation process, it was not possible to gain a satisfactory understanding of the issues confronting these communities and those providing services in them. Due to its size and diverse population and needs, the consultation process included Lightning Ridge in Walgett LGA.

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4. Key findings – The problem of suicide and community and service responses

As stated in the aims and approach, the purpose of the consultations was to canvas a range of opinions on suicide; local risk factors; current infrastructure, service, and workforce gaps; and what can be done to prevent suicide at a local level. The information presented in the following two sections represents stakeholders’ perceptions of these issues.

4.1 Perception of problem(s) The perception of suicide as a problem across the four trial sites reflected different personal and professional experiences. Both within health and community services and the broader community, informants reported differing views on the prevalence of suicidal behaviour. In many cases, this appeared to reflect the personal impact felt by individuals and communities following a death by suicide regardless of actual numbers, as well as the perceived vulnerability of certain groups. Disparities also occurred within health services, particularly regarding the prevalence of suicidal and self-harming behaviours. Given the lack of data on hospitalisation rates for suicidal and self-harming behaviours and that not all of those who engage in suicidal and self-harming behaviours seek help, it is difficult to measure the extent of the problem within the communities involved in the trial. However, there was a perception that self-harm was an issue of concern, particularly among youth. While youth were consistently identified as a vulnerable population across the trial sites, informants also identified other target populations for suicide prevention activity. These included those working in mining (Cobar), those in farming occupations (Walgett), and aged migrant men (Lightning Ridge). Aboriginal and Torres Strait Islander peoples were not overtly identified as at risk; nevertheless, it was implied in discussions around intergenerational trauma, poverty, and disadvantage, and the resultant problems they faced. Moreover, due to the high Aboriginal populations in the four trial sites there was an assumption that Aboriginal people were a large part of the discussion.

4.2 Clinical and service level responses Informants identified a number of issues related to clinical and service level responses to the treatment and care of suicidal persons and those at risk. 4.2.1 Crisis support A lack of acute services and trained mental health practitioners across the trial sites placed enormous strain on emergency department staff when dealing with critical mental health incidents including suicidal and self-harming behaviours. Because clinical assessment was done via telehealth, and delays in admitting patients to inpatient mental health facilities were frequent given occupational health and safety concerns involving transportation to Dubbo or

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Orange after dark, significant staff resources were often required to care for and monitor patients. This increases during after-hours periods and may be especially challenging for staff when critical incidents involve threats of self-harm and/or alcohol and other drugs. In such cases the police were often the first to respond to critical incidents that occurred after hours, and the response was sometimes seen by communities as unsuitable. Alternatively, the transferral of individuals to the Emergency Department by police was also reported by some informants as creating a poor impression on health professionals and impacting the level and appropriateness of care received. These factors, together with the delays involved in assessment and transportation of persons to inpatient mental health services in Dubbo or Orange, means that some individuals may not disclose their suicidality for fear of being involuntary hospitalised and removed from their community. Informants also reported that some individuals, particularly those hospitalised for alcohol and/or other drug use, were often discharged back to the community immediately due to de-escalation and/or the decreasing effects of alcohol and/or other drugs and subsequent assessments of low risk. The work of Cobar’s Integrated Care Program and the Walgett Complex Case Committee shows the potential of organisations to work together to provide ‘wraparound’ care for those considered at risk, as well as to support families. However, barriers to the establishment of a crisis team able to respond to mental health emergencies in partnership with emergency, health, and social and community services currently exist. These include funding, staffing, and concerns over privacy and ongoing interpersonal relationships within small community settings. 4.2.2 Discharge management and follow-up Informants across all trial sites identified a lack of communication and integration between services with regard to the follow-up of patients discharged from inpatient mental health services. Formal protocols and procedures for the follow-up of patients after discharge from inpatient services are lacking. In the case of patients hospitalised following a suicide attempt or admitted to inpatient mental health facilities, discharge management plans and summaries are provided to the community mental health team only for follow-up. This information is often not made available to the primary care physician or other health providers, or made available in an untimely manner. While problems related to patient record-sharing and the follow-up of resistive patients complicate these issues, informants reported inadequate follow-up and networked support for patients discharged from inpatient mental health services, including follow-up of non-attendances.

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4.2.3 Staff support and training The level of individual staff training and support provided in the workplace was reported to impact the capacity of staff to respond appropriately and effectively to critical mental health incidents. Given the lack of acute mental health services, Emergency Department staff are reliant on the Mental Health Emergency Care telehealth service (MHEC) for specialist mental health assessment. There were differing views on MHEC and the timeliness of their responses across the four trial sites, and in some cases relationships were strained. However, there was unanimous agreement that more could be done to provide professional support and debriefing to health staff during and following critical incidents in the absence of local mental health specialists. The need for increased professional support of the health and mental health workforce was also raised. Informants reported problems of burnout and work related stress among health workers, including Aboriginal Health Workers and those working with little support in community organisations. Informants reported that the level of support provided to workers varied according to the individual, their position, and the relationships they have developed through their own networks. With regard to training, a large proportion of hospital staff reported that they had received no additional training in mental health and alcohol and other drug use, and that university-based training had not equipped them to deal with critical mental health incidents. Informants across different trial sites also reported a lack of cultural competency and the inability of health services to provide an environment that is culturally safe for Indigenous people. The absence of perceived safe and supportive health settings was seen as a potential barrier to the provision of effective treatment and care. 4.2.4 Staffing and funding Consultations revealed a shortage of community mental health and allied health professionals, in particular social workers. There were also clear gaps in services for informal carers/families, and counselling for those who had experienced grief, loss, and sexual and physical abuse. High turnover of staff in health and community services was also a concern of informants across the four trial sites. The retention of staff was considered crucial to the development of positive working relations between services and for the provision of effective care. Consistency, continuity, trust, and familiarity were seen as key to developing strong and caring interpersonal relationships with vulnerable individuals and groups in areas of mental health and suicide prevention. There were diverse views on how these issues could best be addressed – for example, through better incentives for attracting and keeping staff, or through the recruitment, training, and support of local people to fill available roles. While the need for mental health specialists will continue, primary care, non-specialist, and community health workers have an important role to play. Effective leadership and management is therefore essential to

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integrate care, scale-up and provide support and mentorship to non-specialist health and community workers, and build institutional capacity to deliver training [4]. Informants also reported concerns about the way the current commissioning and funding of services discouraged cooperation and integration between service providers, and how changes to service contracts and a lack of trust between services impacted continuity of care. Short term contracts were also a barrier to establishing local relationships and hiring staff.

4.3 Community responses Current targeted suicide prevention activities within the trial sites were reported as sporadic and inconsistent. Most activities centred around community events or the workplace (including schools) with the focus primarily on mental health promotion and education. These activities are coordinated by different groups within the communities. In Cobar, campaigns and school programs delivered by Batyr have been embraced by the wider community, while the Men’s Shed is also active and has good relationships with allied health services who provide health messaging and access to low-key on the spot check-ups, including mental health. The CRRMH’s Rural Adversity Mental Health Program (RAMHP) coordinator is also active in the area – working with mining companies and providing mental health first aid and workplace support skills training to front line staff. In Walgett, the Two River Suicide Prevention Network (funded through Wesley Mission) has run education programs and community events, but at the time of the consultation was inactive. The Manager of Community Development at Walgett Shire Council regularly organises events including those that target mental health promotion. A number of school-based programs are run in Walgett but with limited resources. The NSW Department of Education’s Connected Communities program is unable to fill a funded position in Walgett. Informants in Bourke and Brewarrina reported little in the way of targeted suicide prevention promotion or education, although some informants working in organisations that service these communities reported having received training in Mental Health First Aid and/or other workplace trainings. The Act-Belong-Commit program run through NSW Department of Sport and Recreation and Country Rugby League has provided mental health education to rugby league clubs in all four trial sites from 2014-2017. No reference was made to any specific online programs being used by the community.

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5. Key findings – The scope and focus of trial activities

5.1 Choice and diversity in services Clear disparities in service provision were observed across the four trial sites. Cobar, while experiencing cuts to allied health services, was otherwise relatively well-served and was currently part of a Western NSW integrated care pilot that was already showing significant benefits. Informants in Bourke spoke at length about the array of services available yet how integration was often poor. Brewarrina appeared to have extremely limited services with informants reporting that they must travel to Bourke (approximately 100km). Although there was scope for specific targeted suicide prevention activities, there was a consensus that to most effectively address suicide risk the priority for investment should be in improved mental health, alcohol and other drug, and social service delivery. High quality treatment and appropriate and continuing care after leaving Emergency Departments are core evidence-based best practice strategies for suicide prevention [5]. Improving local capacity and support for communities to provide acute and crisis care for vulnerable individuals should therefore be a key focus of suicide prevention activity. From a service user perspective, informants reported that diversity of services and choice were crucial. There was genuine concern expressed by many informants about the appropriateness of e-health or tele-health services and their suitability for those in remote communities. However, in some cases these were seen as a viable alternative for those concerned about confidentiality or who had disengaged from existing services. Diversity and real choice in services were what was important. Yet many informants felt that service-users were not actually given a choice, and that services were designed around the needs of service providers and funding bodies rather than service users. A reported lack of engagement and disengagement from services, together with poor adherence to treatment regimens, posed further concerns regarding the appropriateness of current services/treatments. In addition to improving local capacity to provide acute and crisis care through education, training, improved service integration, and formal and structured supports, informants also spoke of the value of providing less formal non-medical support services. People can be distressed and suicidal without being psychiatrically disordered. Unemployment, homelessness, contact with the criminal justice system, and difficulties in home and work environments all contribute to suicidal risk [6]. The prevalence of these issues across the four trial sites and the identified need for social workers is evidence of the need for services that address these social concerns and their impact on mental health and wellbeing. Informal drop-in spaces that had previously and successfully operated in Lightning Ridge and Bourke, as well as an informal professional counselling service that operated in Cobar as part of an Emergency Drought Assistance Package, suggest there is specific community need for social support and activities. Because such services operate on small budgets, lack evidence of

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effectiveness as a suicide prevention intervention, and exist outside of health services and health service funding, their value is often not understood. Such services require more structured support and funding as potential sites of suicide prevention activity.

5.2 Professional and community education and awareness Informants identified some scope for specific targeted suicide prevention activities in communities and groups, such as professional and community education and awareness. However, there was a consensus that programs be suited to local contexts and that communities and workplaces have a say in the design, choice, and delivery of programs. For example, many health and community professionals reported a lack of recent training in mental health and stated that training in this area would be beneficial. However, informants cautioned against the use of ‘one-size-fits-all’ programs that did not take into consideration the challenges facing remote services with regards to resources, and that programs designed for those working in urban locales may be impractical and create unrealistic expectations for those working in remote areas. Similarly, many informants talked about the value of improving community awareness around mental health and suicide, yet there were differing opinions on the design and content of these programs. The view that messaging be consistent so that everyone was ‘speaking the same language’ was put forward by one informant, yet the needs of different groups (for example, teachers, health service staff, school children, community members, and so forth) suggested that messaging had to be adapted to meet these different needs. Informants also had different views on whether messaging should directly address the issue of suicide and suicidal behaviour or whether programs should focus on the health, social, and emotional issues that contribute to it. Suicide was seen as a sensitive topic and some informants worried that a direct focus on suicide in education programs may discourage some from participating in local activities. Both Aboriginal Mental Health First Aid (AMHFA) and Red Dust Healing are well-established and recognised national programs with promising evidence to support those who wish to undertake suicide prevention activity in Indigenous communities [7]. There are issues with the length of AMHFA and the 14 hours required to deliver the training may be a barrier to its take-up among the wider community. The focus of AMHFA on identification and referral of those at risk is also an issue in these communities where there is a perceived lack of appropriate services. In Bourke, Brewarrina, and Walgett where the Indigenous populations are particularly high, there was expressed desire for, or valuing of, programs or initiatives that focused on building cultural identity, social and emotional wellbeing, and healing – particularly for youth. The strong cultural and strengths based focus of Red Dust Healing and its focus on intergenerational disadvantage and trauma make it especially suited to the wider Indigenous communities in the area.

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Informants also reported that trauma in the context of physical and sexual abuse, drug and alcohol use, and social, economic, and political exclusion rather than mental ill health were the major contributors to heightened vulnerability to suicide and self-harm. Education programs informed by an understanding of trauma and its impacts were therefore seen as critical to suicide prevention activity through building identity, social and emotional wellbeing, and healing [6]. In addition, training in the delivery of effective trauma informed care to health professionals will improve cultural competence and is less likely to re-traumatise those already exposed to significant trauma, and to better engage them in health care [8,9]. A broader focus on social and emotional wellbeing rather than mental illness was also evident in informants’ descriptions of the problems besetting those individuals seen to be at risk. In addition to trauma – unemployment, bullying, domestic violence, problems at school, work and home, and lack of hope and grief over lost family and friends were identified as issues of community concern. These problems were often seen as being perpetuated by intergenerational poverty, social exclusion, and trauma. Education programs that equip families and communities to engage in difficult discussions around these issues would help build community capacity to care for vulnerable people in the community. Informants also expressed concern about young people’s difficulties in expressing feelings, managing conflict, and seeking help, and there was an expressed need for school-based programs for primary school children in this area. In addition to concerns about content, informants also reported problems with the way information was delivered to the community. Didactic approaches based on the provision of suicide prevention related information by experts to a passive target audience were considered ineffective means of communicating to groups such as Aboriginal and Torres Strait Islander peoples and those working in farming occupations. Consideration, therefore, needs to be given to the way messaging is delivered to these groups. Informal opportunistic approaches that are designed around or utilise existing social activities or events may be more effective. Programs for those resistant to talk-based approaches should also utilised where appropriate [6].

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6. Lessons learnt The lack of rationale provided for Western NSW (and the four individual trial sites) being chosen as part of the National Suicide Prevention Trial posed a number of concerns. Coronial data accessed by CRRMH prior to commencing the consultations showed that in the previous five years the number of suicides across the trial sites was relatively low, and that Indigenous suicide rates were lower than suicides by non-Indigenous Australians. We therefore felt it was important to raise this issue with informants as the communities selected have been long, and in our view wrongly, considered dysfunctional. A deficit model sustained by media representations, health promotion, and research reinforces these stereotypes [10]. The approach set out in the National Suicide Prevention Trial Background and Overview that allows for a shifting of power and decision-making to communities is therefore welcome [1]. At the same time, we have come to recognise that the process of consultation in which we engaged, and that forms the basis upon which suicide prevention activities will be delivered to the communities, may not fully accord with the principles of community governance and empowerment set out in local, state, and national policy. This is especially salient when working with Aboriginal communities. Through the Australian Government’s Indigenous Advancement Strategy (IAS), the Federal Government is committed to ensuring Aboriginal and Torres Strait Islander peoples are responsible for determining local service delivery priorities in partnership with government and non-government organisations, and based on agreed local priorities [11]. In Western NSW, governance arrangements are in place with the Murdi Paaki Regional Assembly serving as the peak representative structure representing the interests of Aboriginal and Torres Strait Islander people in 16 communities across Western NSW. At the community level, Community Working Parties (CWPs) are the representative bodies for government and non-government organisations to consult and engage with, while also setting priorities around closing the gap and eliminating social issues for their community [12]. Through these governance arrangements, “Murdi Paaki Regional Assembly and constituent Community Working Parties maintain a commitment to having the authoritative say in the way services are delivered in their communities” [12]. To this end, equitable partnerships between Community Working Parties and government agencies that strengthen community governance, capacity, and leadership, and that work in partnership to develop programs and services that meet local needs are required [12]. As we have clearly stated in the individual work plans developed for each trial site, we see the consultative process started by us as an important first step in an ongoing process of community and service engagement and development underpinned by principles of co-design, co-production, co-leadership and mutual learning between the local community, local service providers, WNSW PHN, and the Federal Government [13]. We hope that work plans will be designed, implemented, and evaluated in collaboration with Community Working

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Parties to ensure the participation of Aboriginal communities in decision making on crucial matters of suicide prevention. This, we believe, is important in making sure that suicide prevention activities meet local priorities, and can be integrated within the system of mental health and related services already established. Finally, through our meetings with a wide array of community members working across community health and social services, local government, schools, church and volunteer groups, universities, emergency services, and with other representative of the local community, the depth of the problems facing these remote communities left an indelible mark on us. As rural health researchers we are well versed in the problems confronting rural and remote communities with regard to mental health service access, lack of specialist care, as well as the ongoing structural, economic, and social changes unique to Australian rural communities. The stark reality of seeing these problems on the ground left us apprehensive about current suicide prevention activity and its continued focus on health sector reforms. While such reforms are important – especially in light of improving mental health services and service integration – informants expressed a need for programs that dealt with the underlying social issues impacting poor social and emotional wellbeing and suicidal distress such as unemployment, poverty, contact with the criminal justice system, and homelessness. Addressing suicide and suicide risk in rural and remote communities requires concurrent action to specifically target these factors [14]. The challenges going forward are twofold. First, suicide prevention organisations must expand their reach and develop partnerships with non-health sector organisations to design and implement programs and interventions that address the social issues impacting social and emotional wellbeing in these communities. Second, local, national, and federal governments must work to ensure the scope and funding of suicide prevention activities extends beyond the health sector to address these social problems and to achieve integrated solutions across sectors.

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7. Conclusion The National Suicide Prevention Trial marks an important step in the design and delivery of suicide prevention and related activities to rural and remote communities by adopting a local community based approach focused on local needs. The communities selected as part of this trial were receptive to this approach and it generated considerable goodwill among community members wishing to improve suicide prevention activities and health and social service delivery. To maximise this and to ensure the successful implementation and sustainability of programs and activities, communities should be involved in an ongoing process of consultation based upon concepts of co-design, co-production, co-leadership and mutual learning. Funding under the National Suicide Prevention Trial provides an opportunity to improve suicide prevention activity targeting and service delivery to meet rural and remote community needs, and to evaluate these activities in order to build an evidence base of effective strategies. However, the time limitations and narrow focus of the trial may constrain the development and integration of social programs and activities within the specific health focus of the trial. It is also likely to be powerless to address the deep seated structural problems that contribute to suicidal behaviour in these communities, and the capacity of services and communities to adequately respond.

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8. References

1. Commonwealth Government of Australia. (2017). National suicide prevention trial: Background and overview. Canberra: Commonwealth Government of Australia.

2. Australian Bureau of Statistics (2017) 2016 Census. Canberra: Australian Bureau of Statistics.

3. NSW Ombudsman. (2010). Inquiry into service provision to the Bourke and Brewarrina communities. A special report to parliament under section 31 of the ombudsman act 1974. Sydney. Available from https://www.ombo.nsw.gov.au/__data/assets/pdf_file/0018/3348/SR_ServiceProvisionBourke_Dec10.pdf [accessed 23 November 2017]

4. Kakuma, R., Minas, H., van Ginneken, N., Dal Poz, M.,Desiraju, K., Morris, J., et al. (2011). Human resources for mental health: Current situation and strategies for action. The Lancet, 378(9803):1654-1663.

5. Black Dog Institute. (2016). LifeSpan integrated suicide prevention: Summary paper. Available from http://www.lifespan.org.au/wp-content/uploads/2016/07/LifeSpan_Summary-Paper_July_2016.pdf [Accessed 23 November 2017]

6. World Health Organization. (2014). Preventing suicide: A global imperative. Geneva. Available from http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/ [Accessed 23 November 2017]

7. Dudgeon, P., Milroy, J., Calma, T., Luxford, Y., Ring, I., Walker, R., et al. (2016). Solutions that work: What the evidence and our people tell us. Aboriginal and Torres Strait Islander suicide prevention evaluation project report. Crawley, Western Australia: School of Indigneous Studies, University of Western Australia. Available from http://www.atsispep.sis.uwa.edu.au/__data/assets/pdf_file/0006/2947299/ATSISPEP-Report-Final-Web.pdf [Accessed 23 November 2017]

8. Milroy, H., Dudgeon, P., & Walker, R. (2013). Community life and development programs – pathways to healing, working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice, pp. 319–334. Canberra: Commonwealth of Australia.

9. Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma informed care in medicine: Current knowledge and future research directions. Family and Community Health, 38(3): 216-226.

10. Pyett, P., Waples-Crowe, P., & van der Sterren, A. (2008). Challenging our own practices in Indigenous health promotion and Research. Health Promotion Journal of Australia, 19(3):179-183.

11. Commonwealth Government of Australia. (2017). Indigenous advancement strategy. Canberra: Commonwealth Government of Australia. Available from https://www.pmc.gov.au/indigenous-affairs/indigenous-advancement-strategy

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12. Murdi Paaki Regional Assembly. 2015. Charter of Governance. Broken Hill: Murdi Paaki Regional Assembly. Available from http://www.mpra.com.au/uploads/documents/MPRA%20Charter%20of%20Governance.pdf [Accessed 23 November 2017]

13. Ramsden, V.R., Salsberg, J., Herbert, C.P, Westfall, J.M., LeMaster J., & Macaulay, A.C. (2017). Patient and Community-Oriented Research. Canadian Family Physician, 63: 74-76.

14. Smith, K.B., Humphreys, J.S., & Wilson, M.G.A. (2008). Addressing the health disadvantage of rural populations: How does epidemiological evidence inform rural health policies and research. Australian Journal of Rural Health, 16:56-66.

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9. Appendix A: List of organisations consulted Bourke LGA Bourke High School, Bourke District Hospital, Bourke Shire Council, Bourke Community Health Centre, Corrective Services NSW, Flourish, Interrelate, Live Better, Maranguka Justice Reinvestment Project, Mission Australia, NSW Ambulance Service, NSW Police Force, Outback Division of General Practice, Rural and Remote Medical Services, and the University of Sydney. Brewarrina LGA Brewarrina Aboriginal Health Service (BAHS), Ngemba Community Working Party, Murdi Paaki Regional Assembly, Brewarrina Multipurpose Health Centre, NSW Department of Primary Industries, McKillop Rural Family Services, Rural and Remote Medical Services (RaRMS), Brewarrina Central School, and St Patrick’s School. Cobar LGA Cobar Primary Health Care Centre, Outback Division of General Practice (ODGP), AWI Consulting, Cobar Community Health Centre, Royal Flying Doctor Service, Cobar High School, Cobar Youth and Fitness Centre, Western NSW Local Health District and community members representing Australian Men’s Shed, Batyr (Youth Mental Health Promotion), NSW Fire Service, and the local health council. Walgett LGA Walgett Aboriginal Medical Service (WAMS), Dharriwaa Elders Group, Walgett Multi-Purpose Health Service, Walgett Community College, LiveBetter, NSW Ambulance Service, Outback Division of General Practice, Lightning Ridge Multi-Purpose Health Service, Lightning Ridge Central School, St Peter’s Anglican Church, Department of Primary Industries, Western Local Health District and Walgett Community Health Service.

Centre for Rural and Remote Mental Health

T + 61 2 6363 8444 F +61 2 6361 2457 E crrmh.@newcastle.edu.au Locked Bag 6005 Orange NSW 2800